GOLDENWOOD SERVICES, LLC
NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
Notice of Patient Privacy (NPP)
Notice of Privacy Practices (NPP)
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are required by federal law (Health Insurance Portability and Accountability Act, or HIPAA, U.S. Congress) to maintain the privacy of your Protected Health Information (“PHI”). PHI is personal information about you, including demographic information that we collect from you, that may be used to identify you and relates to your past, present, or future physical or mental health or condition, including treatment and payment for the provision of healthcare.
This Notice explains our legal duties and privacy practice with regard to your PHI. We are required by federal law to provide you with a copy of this Notice and to abide by the terms of this Notice. Accordingly, we will ask you to sign a statement acknowledging that we have provided you with a copy of the Notice. If you have elected to receive a copy electronically, you still have the right to obtain a paper copy upon request.
I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS We intend to limit the disclosure of your PHI to that necessary for Treatment, Payment, and Operations. Although Federal Law states that I do not need your written authorization to use or disclose your PHI for treatment, payment, or health care operations, our professional code of ethics states that we do, and you will therefore by asked for your written authorization even though it is not legally necessary.
· Treatment refers to specific sharing and use of your PHI relating to your direct care (provision, coordination, and management) by our employees, including consulting other professionals and the use of disease management programs. For example, we will disclose your PHI to another health care professional, such as your family physician or another psychologist, nursing home staff or a testing facility to which you have been referred for care or for assistance with treatment.
· Payment refers to specific sharing and use of your PHI for purposes of obtaining payment for our treatment of you, including billing and collection activities, related data processing and disclosure to consumer reporting agencies. For example, your PHI will be disclosed on forms we submit to your insurance to obtain reimbursement for your health care or to determine eligibility receive payment.
· Operations refer to specific sharing and use of your PHI necessary for our administrative and technical operations, within the limitations imposed by professional ethics. Permissible activities would include, but are not limited to, accounting or legal activities, quality assessment and improvement activities, case management, care coordination, employee review, student/intern training, and other business activities such as audits and administrative services. For example, we might need to disclose your PHI to a psychologist for peer review of records, or to accounting for billing purposes.
· Use applies only to activities within our office (clinic, practice group, etc.) such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· Disclosure applies to activities outside our office (clinic, practice group, etc.) such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment, and operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that 1) we have relied on that authorization; or 2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
Psychotherapy notes are notes recorded (in any medium) by a healthcare provider who is a mental health professional documenting or analyzing the contents of conversation during a private, group, joint, or family counseling session. These notes are considered to be highly confidential in nature and the psychotherapist-patient privilege requires heightened level of concern regarding the privacy of the information contained in the notes. Since psychotherapy notes are often used only by the therapist who wrote them and are maintained separately from the medical record it is necessary to use a separate authorization for this request.
Psychotherapy notes DO NOT include the following:
· Medication or prescription records,
· Monitoring or counseling session start and stop times,
· Modalities and frequencies of treatment furnished,
· Results of clinical tests, and
· Any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date
This information would be included in your general treatment record, and would be available for treatment, payment, and healthcare operations, restricted by the “minimum necessary” provision for payment and healthcare operations.
Your refusal to provide such authorization will not affect our duty to treat you. Such authorization cannot be compelled for payment, underwriting, or plan enrollment. (Health plans cannot condition enrollment, eligibility for benefits, or payment of a claim on obtaining a person’s authorization to use or disclose psychotherapy notes.)
We must obtain individual (not to be combined with another authorization) written authorization for the disclosure of psychotherapy notes for all requests EXCEPT for the following reasons:
· Use by the originator of the psychotherapy notes for treatment;
· Use or disclosure by the covered entity in the professional training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling;
· Use or disclosure by the covered entity to defend a legal action or other proceeding brought by the patient;
· Use or disclosure of psychotherapy notes by an oversight agency such as the Secretary of Health and Human Services, or any other officer or employee of the Department of Health and Human Services to whom the authority has been delegated, to conduct enforcement activities;
· Use or disclosure needed for oversight of employees of covered entity who created the psychotherapy notes
· Use or disclosure needed by a medical examiner or coroner for the purpose of identifying a deceased person, determining the cause of death, or other duties as authorized by law; or
· When we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
We will not permit the following disclosures without your written authorization:
· Marketing
· To your employer, except where necessary for provision of care or payment purposes (for example, if your employer is self-insured).
· Disclosures outside our offices, unless for treatment, payment, or operations.
· For research purposes, unless certain safeguards are taken.
III. Uses and Disclosures with Neither Consent nor Authorization We may make disclosures in certain situations as required by law, even without your written authorization. These situations include, but are not limited to:
· De-identified PHI--If all identifying information is removed so your identity cannot be ascertained from the information disclosed, i.e., on a completely anonymous basis.
· Public health authority as required by law. Laws require the reporting of suspected child abuse, elder abuse, or other such reports.
· Child Abuse--We are required to report PHI to the appropriate authorities when we have reasonable grounds to believe that a minor is or has been the victim of neglect or physical and/or sexual abuse.
If I have reason to suspect, on the basis of my professional judgment, that a child is or has been abused, I am required to report my suspicions to the authority or government agency vested to conduct child-abuse investigations. I am required to make such reports even if I do not see the child in my professional capacity.
I am mandated to report suspected child abuse if anyone aged 14 or older tells me that he or she committed child abuse, even if the victim is no longer in danger.
I am also mandated to report suspected child abuse if anyone tells me that he or she knows of any child who is currently being abused.
· Adult and Domestic Abuse—If we have the responsibility for the care of an incapacitated or vulnerable adult, we are required to disclose PHI when we have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult’s property has occurred.
· Serious Threat to Health or Safety--If you communicate to us an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and we believe you have the intent and ability to carry out such a threat, we have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. If we believe that there is an imminent risk that you will inflict serious harm on yourself, we may disclose information in order to protect you. If patient reports that he or she is a danger to self or others, that there is a chance of suicide or homocide attempt, the therapist may have to inform family members, police, intended victims of a crime, and/or local hospitals.
· When required by law, for example, public health reporting purposes or to a person who may be affected by a communicable disease.
· Health Oversight Purposes as authorized by law, for example, an investigation of our practice by the Pennsylvania Board of Psychology for purposes unrelated to your treatment.
· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that we have provided you and/or the records thereof, such information is privileged under state law, and we will not release this information without written authorization of you or your legally appointed representative or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Court subpoena’s may override confidentiality. Cases involving accidents, liability or malpractice may require an end to confidentiality
· Worker’s compensation law--(or a similar law). For example, if you file a worker’s compensation claim, and we are treating you for the issues involved with that complaint, we may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illnesses without regard to fault. Similarly, we may disclose PHI to your employer, if we are providing care to you at your employer’s request to evaluate a work-related illness or injury, or medical surveillance of your workplace.
· To law enforcement for certain purposes, including pursuant to a warrant or court order.
· To the U.S. Food and Drug Administration, in the event of an adverse event.
· For national security and intelligence purposes, military or veteran’s activities, or to correctional institutions.
· Decedents--To coroners or funeral directors regarding deceased individuals
· Certain information may be communicated to parents of a minor
· Certain information may be conveyed to billing companies, collection agencies, professional staff and care providers. Our professional staff of psychologists and therapists consult with each other at appropriate times regarding our work with patients, for supervisory sessions and for quality of care. Administrative staff have access to patient information and maintain appropriate confidentiality. Information pertinent only to the collection of past due fees are revealed. Patient agrees to allow uncollected fees to be turned over to a collection agency.
· Insurance companies and third party payers. Filing insurance claims releases diagnosis, service and dates. Insurance companies may require patient treatment information.
· There may be publication or other educational or research uses of data collected during treatment. Any identifying information will be deleted and no information that identifies the patient will be released without the patient’s separate consent unless required by law.
IV. PATIENT RIGHTS You have these rights as a patient:
1. The right to consider and sign an authorization for a non-authorized use. The law only allows us to use or disclose your PHI in certain circumstances, as explained above. If we need to make a use or disclosure that does not fall into one of those exceptions—including the disclosure of psychoeducational records to schools or results of psychological evaluations to employers—we will ask you to sign an authorization. If we do not have a valid authorization on file specifically authorizing the proposed use or disclosure, then we will not make that use or disclosure. You may revoke an authorization at any time in writing, but the revocation will not apply to uses or disclosures that we have already made in reliance on your original authorization.
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.) (Amended 9/23/13).
2. The right to access your PHI. You have a right to access and receive a copy, summary, or explanation of your PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We have the right to deny you access under certain circumstances, such as psychotherapy notes, information compiled in reasonable anticipation of legal action, and confidential information relating to certain lab tests, but you will be notified of the reason for denial and be given the right to have the denial reviewed under certain circumstances. If you have elected to receive a copy electronically, you still have the right to obtain a paper copy upon request. You have a right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information (Amended 9/23/13).
3. The right to request restrictions on certain uses and disclosures. You may request restrictions of certain uses or disclosures of your PHI when it is used to carry out your treatment, obtain payment for your treatment or to perform healthcare operations of our practice. You must request the restriction before we have used or disclosed the relevant information. We are not required to agree to the restriction, and we have the right to decide not to accept the restriction and not to treat you.
If you are self-pay, then you may restrict the information sent to insurance companies(Amended 9/23/13).
4. The right to receive confidential communications. You may request that we make confidential communications to you by an alternative means or at an alternative location. The request must be in writing, but we will not ask for an explanation from you. We will accommodate reasonable requests, but we may condition the accommodation on information as to how payment, if any, will be handled and specification of an alternative address or other method of contact. For example, you may not want a family member to know that you are being seen by us. Upon written request, we will send your bills or contact you by an alternative address or method.
5. The right to amend PHI. You have the right to ask to request an amendment of PHI for as long as the PHI is maintained in our record. We have the right to deny your request for amendment, if we determine that your record was not created by us, is not maintained by us, would not be available for access, or is accurate and complete. Your records will not be changed or deleted as a result of our granting your request, but the amendment will be attached to your record and its existence noted in your record as necessary. (Note: use of this procedure is not necessary for routine changes to your demographic information, such as address, phone number, etc.)
6. The right to receive an accounting. You have the right to receive an accounting of our uses and disclosures of your PHI. You will need to complete this form and submit it to us. The accounting does not have to list disclosures made (i) to carry out treatment, payment and healthcare operations; (ii) to you; (iii) pursuant to an authorization; (iv) for national security or intelligence purposes; (v) to correctional institutions or law enforcement personnel or (vi) that occurred prior to April 14, 2003. (Note: compliance with this right is time-consuming, and so we reserve the right to charge you a fee if your request more than one accounting in a twelve-month period.)
V. OUR DUTIES
· We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.
· If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified (Amended 9/23/13).
· We reserve the right to change the privacy policies and practices described in this notice. The change may be retroactive and cover PHI that we received or created prior to the revision. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we do change the Notice, a copy of the new Notice will be posted in the waiting room and on our website, if any. We will provide you with a copy of the revised Notice upon your request.
VI. ORGANIZATIONAL POLICIES To facilitate the smooth and efficient operation of our practice, we engage in certain practices and policies that you should understand. You can avoid any of the following practices by discussing your concerns with us and working out an alternative:
· We contact our patients by telephone (which might include leaving a message on an answering machine or voice mail) or mail to provide appointment reminders or routine test results.
· We use sign-in sheets and call out names in our waiting room to manage patient flow.
· Our staff will conduct routine discussions at the front desk with patients.
· We may contact our patients by telephone or mail to provide information about treatment alternatives or other health-related benefits and services that may be of interest.
· We may use your name and address to send you a newsletter about our practice and the services that we offer.
· We may disclose your PHI to a member of your family or a close friend that relates directly to that person’s involvement in your healthcare.
You should also be aware of the following policies regarding our uses and disclosures of your PHI. You cannot avoid these uses and disclosures, but you should discuss any questions or concerns you might have with us:
· We share PHI with third-party “business associates” that perform various function for us (for example, billing and transcription), but we have written contracts with those entities containing terms that require protection of your PHI.
· We may disclose your PHI to your personal representative(s), if any, unless we determine in the exercise of our professional judgment that such disclosures should not be made.
VII. QUESTIONS AND COMPLAINTS
If you have any questions about this Notice, the matters discussed herein or anything else related to our privacy policy, please feel free to ask for an appointment to speak with our Privacy and Security Officer at 215-479-6439.
You may complain to our Privacy and Security Officer or the United States Secretary of Health and Human Services if you believe your privacy rights have been violated. To complain to the Secretary, your complaint must be in writing, name us, describe the acts or omissions believed to be in violation of your privacy rights and be filed within 180 days of when you knew or should have known that the act or omission occurred. We will not retaliate against you for filing a complaint. If you want further information about the complaint process, please talk to your Privacy and Security Officer.
VIII. EFFECTIVE DATE
This notice is in effect as of April 14, 2003.
Ammended September 23, 2013
If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.
If you are self-pay, then you may restrict the information sent to insurance companies.
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.).
You have a right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information.
GOLDENWOOD SERVICES, LLC
Notice of Privacy Practices
Written Acknowledgement Form
I, ________________________________________________________, have received and read a copy of
Goldenwood Services, LLC Notice of Privacy Practices.
This form constitutes receipt of the Notice of Privacy Practices written acknowledgement form.
__________________________________________________________________ _________________
Signature of patient Date
NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
Notice of Patient Privacy (NPP)
Notice of Privacy Practices (NPP)
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are required by federal law (Health Insurance Portability and Accountability Act, or HIPAA, U.S. Congress) to maintain the privacy of your Protected Health Information (“PHI”). PHI is personal information about you, including demographic information that we collect from you, that may be used to identify you and relates to your past, present, or future physical or mental health or condition, including treatment and payment for the provision of healthcare.
This Notice explains our legal duties and privacy practice with regard to your PHI. We are required by federal law to provide you with a copy of this Notice and to abide by the terms of this Notice. Accordingly, we will ask you to sign a statement acknowledging that we have provided you with a copy of the Notice. If you have elected to receive a copy electronically, you still have the right to obtain a paper copy upon request.
I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS We intend to limit the disclosure of your PHI to that necessary for Treatment, Payment, and Operations. Although Federal Law states that I do not need your written authorization to use or disclose your PHI for treatment, payment, or health care operations, our professional code of ethics states that we do, and you will therefore by asked for your written authorization even though it is not legally necessary.
· Treatment refers to specific sharing and use of your PHI relating to your direct care (provision, coordination, and management) by our employees, including consulting other professionals and the use of disease management programs. For example, we will disclose your PHI to another health care professional, such as your family physician or another psychologist, nursing home staff or a testing facility to which you have been referred for care or for assistance with treatment.
· Payment refers to specific sharing and use of your PHI for purposes of obtaining payment for our treatment of you, including billing and collection activities, related data processing and disclosure to consumer reporting agencies. For example, your PHI will be disclosed on forms we submit to your insurance to obtain reimbursement for your health care or to determine eligibility receive payment.
· Operations refer to specific sharing and use of your PHI necessary for our administrative and technical operations, within the limitations imposed by professional ethics. Permissible activities would include, but are not limited to, accounting or legal activities, quality assessment and improvement activities, case management, care coordination, employee review, student/intern training, and other business activities such as audits and administrative services. For example, we might need to disclose your PHI to a psychologist for peer review of records, or to accounting for billing purposes.
· Use applies only to activities within our office (clinic, practice group, etc.) such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· Disclosure applies to activities outside our office (clinic, practice group, etc.) such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment, and operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that 1) we have relied on that authorization; or 2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
Psychotherapy notes are notes recorded (in any medium) by a healthcare provider who is a mental health professional documenting or analyzing the contents of conversation during a private, group, joint, or family counseling session. These notes are considered to be highly confidential in nature and the psychotherapist-patient privilege requires heightened level of concern regarding the privacy of the information contained in the notes. Since psychotherapy notes are often used only by the therapist who wrote them and are maintained separately from the medical record it is necessary to use a separate authorization for this request.
Psychotherapy notes DO NOT include the following:
· Medication or prescription records,
· Monitoring or counseling session start and stop times,
· Modalities and frequencies of treatment furnished,
· Results of clinical tests, and
· Any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date
This information would be included in your general treatment record, and would be available for treatment, payment, and healthcare operations, restricted by the “minimum necessary” provision for payment and healthcare operations.
Your refusal to provide such authorization will not affect our duty to treat you. Such authorization cannot be compelled for payment, underwriting, or plan enrollment. (Health plans cannot condition enrollment, eligibility for benefits, or payment of a claim on obtaining a person’s authorization to use or disclose psychotherapy notes.)
We must obtain individual (not to be combined with another authorization) written authorization for the disclosure of psychotherapy notes for all requests EXCEPT for the following reasons:
· Use by the originator of the psychotherapy notes for treatment;
· Use or disclosure by the covered entity in the professional training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling;
· Use or disclosure by the covered entity to defend a legal action or other proceeding brought by the patient;
· Use or disclosure of psychotherapy notes by an oversight agency such as the Secretary of Health and Human Services, or any other officer or employee of the Department of Health and Human Services to whom the authority has been delegated, to conduct enforcement activities;
· Use or disclosure needed for oversight of employees of covered entity who created the psychotherapy notes
· Use or disclosure needed by a medical examiner or coroner for the purpose of identifying a deceased person, determining the cause of death, or other duties as authorized by law; or
· When we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
We will not permit the following disclosures without your written authorization:
· Marketing
· To your employer, except where necessary for provision of care or payment purposes (for example, if your employer is self-insured).
· Disclosures outside our offices, unless for treatment, payment, or operations.
· For research purposes, unless certain safeguards are taken.
III. Uses and Disclosures with Neither Consent nor Authorization We may make disclosures in certain situations as required by law, even without your written authorization. These situations include, but are not limited to:
· De-identified PHI--If all identifying information is removed so your identity cannot be ascertained from the information disclosed, i.e., on a completely anonymous basis.
· Public health authority as required by law. Laws require the reporting of suspected child abuse, elder abuse, or other such reports.
· Child Abuse--We are required to report PHI to the appropriate authorities when we have reasonable grounds to believe that a minor is or has been the victim of neglect or physical and/or sexual abuse.
If I have reason to suspect, on the basis of my professional judgment, that a child is or has been abused, I am required to report my suspicions to the authority or government agency vested to conduct child-abuse investigations. I am required to make such reports even if I do not see the child in my professional capacity.
I am mandated to report suspected child abuse if anyone aged 14 or older tells me that he or she committed child abuse, even if the victim is no longer in danger.
I am also mandated to report suspected child abuse if anyone tells me that he or she knows of any child who is currently being abused.
· Adult and Domestic Abuse—If we have the responsibility for the care of an incapacitated or vulnerable adult, we are required to disclose PHI when we have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult’s property has occurred.
· Serious Threat to Health or Safety--If you communicate to us an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and we believe you have the intent and ability to carry out such a threat, we have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. If we believe that there is an imminent risk that you will inflict serious harm on yourself, we may disclose information in order to protect you. If patient reports that he or she is a danger to self or others, that there is a chance of suicide or homocide attempt, the therapist may have to inform family members, police, intended victims of a crime, and/or local hospitals.
· When required by law, for example, public health reporting purposes or to a person who may be affected by a communicable disease.
· Health Oversight Purposes as authorized by law, for example, an investigation of our practice by the Pennsylvania Board of Psychology for purposes unrelated to your treatment.
· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that we have provided you and/or the records thereof, such information is privileged under state law, and we will not release this information without written authorization of you or your legally appointed representative or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Court subpoena’s may override confidentiality. Cases involving accidents, liability or malpractice may require an end to confidentiality
· Worker’s compensation law--(or a similar law). For example, if you file a worker’s compensation claim, and we are treating you for the issues involved with that complaint, we may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illnesses without regard to fault. Similarly, we may disclose PHI to your employer, if we are providing care to you at your employer’s request to evaluate a work-related illness or injury, or medical surveillance of your workplace.
· To law enforcement for certain purposes, including pursuant to a warrant or court order.
· To the U.S. Food and Drug Administration, in the event of an adverse event.
· For national security and intelligence purposes, military or veteran’s activities, or to correctional institutions.
· Decedents--To coroners or funeral directors regarding deceased individuals
· Certain information may be communicated to parents of a minor
· Certain information may be conveyed to billing companies, collection agencies, professional staff and care providers. Our professional staff of psychologists and therapists consult with each other at appropriate times regarding our work with patients, for supervisory sessions and for quality of care. Administrative staff have access to patient information and maintain appropriate confidentiality. Information pertinent only to the collection of past due fees are revealed. Patient agrees to allow uncollected fees to be turned over to a collection agency.
· Insurance companies and third party payers. Filing insurance claims releases diagnosis, service and dates. Insurance companies may require patient treatment information.
· There may be publication or other educational or research uses of data collected during treatment. Any identifying information will be deleted and no information that identifies the patient will be released without the patient’s separate consent unless required by law.
IV. PATIENT RIGHTS You have these rights as a patient:
1. The right to consider and sign an authorization for a non-authorized use. The law only allows us to use or disclose your PHI in certain circumstances, as explained above. If we need to make a use or disclosure that does not fall into one of those exceptions—including the disclosure of psychoeducational records to schools or results of psychological evaluations to employers—we will ask you to sign an authorization. If we do not have a valid authorization on file specifically authorizing the proposed use or disclosure, then we will not make that use or disclosure. You may revoke an authorization at any time in writing, but the revocation will not apply to uses or disclosures that we have already made in reliance on your original authorization.
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.) (Amended 9/23/13).
2. The right to access your PHI. You have a right to access and receive a copy, summary, or explanation of your PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We have the right to deny you access under certain circumstances, such as psychotherapy notes, information compiled in reasonable anticipation of legal action, and confidential information relating to certain lab tests, but you will be notified of the reason for denial and be given the right to have the denial reviewed under certain circumstances. If you have elected to receive a copy electronically, you still have the right to obtain a paper copy upon request. You have a right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information (Amended 9/23/13).
3. The right to request restrictions on certain uses and disclosures. You may request restrictions of certain uses or disclosures of your PHI when it is used to carry out your treatment, obtain payment for your treatment or to perform healthcare operations of our practice. You must request the restriction before we have used or disclosed the relevant information. We are not required to agree to the restriction, and we have the right to decide not to accept the restriction and not to treat you.
If you are self-pay, then you may restrict the information sent to insurance companies(Amended 9/23/13).
4. The right to receive confidential communications. You may request that we make confidential communications to you by an alternative means or at an alternative location. The request must be in writing, but we will not ask for an explanation from you. We will accommodate reasonable requests, but we may condition the accommodation on information as to how payment, if any, will be handled and specification of an alternative address or other method of contact. For example, you may not want a family member to know that you are being seen by us. Upon written request, we will send your bills or contact you by an alternative address or method.
5. The right to amend PHI. You have the right to ask to request an amendment of PHI for as long as the PHI is maintained in our record. We have the right to deny your request for amendment, if we determine that your record was not created by us, is not maintained by us, would not be available for access, or is accurate and complete. Your records will not be changed or deleted as a result of our granting your request, but the amendment will be attached to your record and its existence noted in your record as necessary. (Note: use of this procedure is not necessary for routine changes to your demographic information, such as address, phone number, etc.)
6. The right to receive an accounting. You have the right to receive an accounting of our uses and disclosures of your PHI. You will need to complete this form and submit it to us. The accounting does not have to list disclosures made (i) to carry out treatment, payment and healthcare operations; (ii) to you; (iii) pursuant to an authorization; (iv) for national security or intelligence purposes; (v) to correctional institutions or law enforcement personnel or (vi) that occurred prior to April 14, 2003. (Note: compliance with this right is time-consuming, and so we reserve the right to charge you a fee if your request more than one accounting in a twelve-month period.)
V. OUR DUTIES
· We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.
· If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified (Amended 9/23/13).
· We reserve the right to change the privacy policies and practices described in this notice. The change may be retroactive and cover PHI that we received or created prior to the revision. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we do change the Notice, a copy of the new Notice will be posted in the waiting room and on our website, if any. We will provide you with a copy of the revised Notice upon your request.
VI. ORGANIZATIONAL POLICIES To facilitate the smooth and efficient operation of our practice, we engage in certain practices and policies that you should understand. You can avoid any of the following practices by discussing your concerns with us and working out an alternative:
· We contact our patients by telephone (which might include leaving a message on an answering machine or voice mail) or mail to provide appointment reminders or routine test results.
· We use sign-in sheets and call out names in our waiting room to manage patient flow.
· Our staff will conduct routine discussions at the front desk with patients.
· We may contact our patients by telephone or mail to provide information about treatment alternatives or other health-related benefits and services that may be of interest.
· We may use your name and address to send you a newsletter about our practice and the services that we offer.
· We may disclose your PHI to a member of your family or a close friend that relates directly to that person’s involvement in your healthcare.
You should also be aware of the following policies regarding our uses and disclosures of your PHI. You cannot avoid these uses and disclosures, but you should discuss any questions or concerns you might have with us:
· We share PHI with third-party “business associates” that perform various function for us (for example, billing and transcription), but we have written contracts with those entities containing terms that require protection of your PHI.
· We may disclose your PHI to your personal representative(s), if any, unless we determine in the exercise of our professional judgment that such disclosures should not be made.
VII. QUESTIONS AND COMPLAINTS
If you have any questions about this Notice, the matters discussed herein or anything else related to our privacy policy, please feel free to ask for an appointment to speak with our Privacy and Security Officer at 215-479-6439.
You may complain to our Privacy and Security Officer or the United States Secretary of Health and Human Services if you believe your privacy rights have been violated. To complain to the Secretary, your complaint must be in writing, name us, describe the acts or omissions believed to be in violation of your privacy rights and be filed within 180 days of when you knew or should have known that the act or omission occurred. We will not retaliate against you for filing a complaint. If you want further information about the complaint process, please talk to your Privacy and Security Officer.
VIII. EFFECTIVE DATE
This notice is in effect as of April 14, 2003.
Ammended September 23, 2013
If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.
If you are self-pay, then you may restrict the information sent to insurance companies.
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.).
You have a right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information.
GOLDENWOOD SERVICES, LLC
Notice of Privacy Practices
Written Acknowledgement Form
I, ________________________________________________________, have received and read a copy of
Goldenwood Services, LLC Notice of Privacy Practices.
This form constitutes receipt of the Notice of Privacy Practices written acknowledgement form.
__________________________________________________________________ _________________
Signature of patient Date